Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
###
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Email
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Date of Pick Up for Cremation
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MM
DD
YYYY
Pet's Name
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Sex
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Please Select One
Pet's Age
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Species
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Breed
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Color
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Approximate Wreight
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How did you hear about us?
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Name of the friend or clinic that referred you:
Special Notes or Requests for the Veterinarian:
Aftercare Preference
*
Please Select One
If shipping ashes please add USPS address below
Additional Memorial Keepsakes
Select any additional memorial keepsakes item(s) you would like to add.
One Paw Pals Paw Print is included with every appointment free of charge.
Name of your pet's primary veterinary clinic:
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Preferred Payment Method
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I, the undersigned, certify that I am the owner or duly authorized agent for the owner, of the animal described above. I do hereby give Buffalo & Beyond Veterinary Services, PLLC Veterinarians, staff and agents complete authority to cremate the animal described above. I release Buffalo & Beyond Veterinary Services, PLLC Veterinarians, staff and agents from any and all liability for cremation of said animal. I certify, to the best of my knowledge, the above animal has not bitten any person or animal during the last 10 days and has not been exposed to rabies.
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Type your name above to digitally sign and check this box to confirm you have read & consent to the statement above
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Winter Weather Policy: During the winter months we ask that you keep a clear path from your drive or on-street parking to your home to ensure Dr. Sverduk can safely come to and from your home for your appointment.
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Date
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MM
DD
YYYY